New Customer Registration Form
Vanaria Landscape Supply, Inc.
Business Information
Customer Name
First Name
Last Name
Company Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Person
*
Phone Number
*
Format: (000) 000-0000.
Accounting Information
Contact Person
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail
*
example@example.com
Do you require POs?
*
Please Select
Yes
No
Are you tax exempt?
*
Please Select
Yes
No
*If yes, please return a copy of your exemption form to the office.
Primary method of payment
*
Please Select
Credit/Debit Card
Cash
Check (at time of sale)
*Note: Please email the office vanlansupply@gmail.com to request that your credit card be kept on file.
How did you hear about us?
Google search
Social Media (Facebook, Instagram, etc.)
Word of mouth
Referral
Website
Other
Reference
Comments/Notes
Signature
*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: